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317 Cards in this Set

  • Front
  • Back
Lecture 92: Med in Society 6
Geriatrics
What are the common SE of B-blockers? Which patient populations should use caution when taking B-blockers?
• Exacerbation of asthma ( non- selective B- blockers)
• Can raise blood glucose
• Can mask symptoms of hypoglycemia
• Bradycardia, AV block
• CHF
A pt. of yours develops hypercalcemia from the most common primary tumor arising within bones in adults. What lab findings would you suspect in this pt?
• Multiple Myeloma
o Hypercalcemia
o Monoclonal antibody spike on UPEP & SPEP
o Bence- Jones proteins in the urine
o Rouleaux formation
o Elevated BUN & Cr
o Lytic bone lesions on skeletal x-rays
What vaginal disorder is common in elderly women?
• Vaginal atrophy
What are the 3 leading causes of death in patients over age 65?
• Heart disease
• Cancer
• Stroke
Which patients should be screened for an abdominal aortic aneurysm using an abdominal ultrasound?
• Men ages 65-75 who have ever smoked
At what age should every geriatric patient have had a DEXA bone density scan?
• DEXA
o All women age 65 and older
o Younger women whose fracture risk is greater than that of a 65yo white woman with no additional risk factors
o USPSTF does not recommend screening
o National osteoporosis foundation: Men ages 50-70 with risk factors, All men at 70
Lecture 93: Med in Society 7
Healthcare system
What patient populations are particularly susceptible to mucomycosis?
• Leukemia
• Diabetic ketoacidosis (DKA)
Chromosomal analysis of leukemia patient reveals the presence of the Philadelphia t(9;22).What is the treatment?
• CML
• Imantinab
Which tumor marker would you use to follow each of the following cancers?
• Ovarian cancer
• Hepatocellular cancer ( Hep B & C patients)
• Pancreatic cancer
• Melanoma
• Colon Cancer
• Astrocytoma
• Ovarian cancer—CA- 125
• Hepatocellular cancer ( Hep B & C patients)—α- fetoprotein
• Pancreatic cancer—CA19-9, CEA
• Melanoma—S- 100
• Colon Cancer—CEA
• Astrocytoma—S- 100
What is the difference a premium, co-pay, and deductible?
• Premium—amount paid to an insurance company
• Co-pay—fee paid out of pocket at the time of service
• Deductible—out of pocket expense paid before insurance begins to pay
Which usually offers patients a greater variety of physicians to choose from: HMO or PPO?
• PPO
What is the difference between being paid by capitation and fee- for- service?
• Fee- for service—payment provided for a specific service
• Capitation—fixed payment for a period of time or number of patients
What must a hospital submit to a third- party payer in order to receive payment for services?
• ICD- 9 diagnosis codes
• CPT service/procedure codes
What department in a hospital oversees the maximization of the quality of care while minimizing the cost of care?
• Utilization management department (utilization review)
Lecture 94: Med in Society 8
Ethics
5 Stars*****
What type of thyroid cancer matches each of the following statements?
• Most common type of thyroid cancer (70-75%)
o Papillary carcinoma
• Second most common type of thyroid cancer (10%)
o Follicular carcinoma
• Activation of receptor tyrosine kinases
o Papillary & medullary carcinoma
• Hashimoto thyroiditis is a risk factor
o Lymphoma
• Cancer arising from parafollicular ( C ) cells
o Medullary carcinoma
Metastasis to the brain, liver, and bone commonly come from which locations?
• Brain
o Lung
o Breast
o Skin (melanoma)
o Kidney (renal cell carcinoma)
o GI tract tumors

• Liver
o Colon
o Stomach
o Pancreas
o Breast
o Lung

• Bone
o Prostate
o Renal cell
o Thyroid/ testes
o Lung/ lymphoma
o Breast
What changes in sleep patterns and sexual anatomy are seen in the elderly?
• Sleep patterns
o Decreased REM sleep
o Decreased slow wave sleep
o Increased sleep latency
o Increase nighttime wakening

• Male sexual anatomy
o Slower erection & ejaculation
o Longer refractory period

• Female sexual anatomy
o Vaginal atrophy
Core ethical principles
• Nonmaleficence
• Beneficence
• Patient autonomy
• Physician autonomy
• Justice
• Privacy
Exceptions to Confidentiality
• Child abuse
• Disease reporting
• Schools
• Employers
Ethical situations
• Maintain a good physician- patient relationship
• Respect the patient’s rights
• Never “punt”
• The golden rule—how would I want to be treated
Malpractice Claim
• Duty
• Breach of duty
• Harm caused by breach of duty
• Damage
What should you do if a minor requests birth control during a clinic visit in the absence of her parents?
• Educate the patient
• Provide the BC
• Preventative care (Pap smear)
How should you handle a situation where you smell alcohol on a physician’s breath while that physician is practicing medicine?
• Notify the physician’s superior
Lecture 95: Pulmonary 1
Anatomy & Physiology
To which lymph nodes do each of the following regions drain?
• Rectum
o Internal iliac nodes
• External anus
o Superficial inguinal nodes
• Testes
o Superficial and deep plexuses ------ para-aortic nodes
• Scrotum
o Superficial inguinal nodes
Which ketone body is metabolized by muscle and brain tissue?
• B- hydroxybutyrate
Which anticancer drug fits each of the following descriptions?
• Fragments DNA, toxicity ---- pulmonary fibrosis
o Bleomycin
• Blocks purine synthesis, metabolized by xanthine oxidase
o 6-mercaptopurine
• Folic acid analog that inhibits dihydrofolate reductase
o Methotrexate
• Prevents tubulin disassembly
o Paclitaxel, taxols
• DNA alkylating agents used in brain cancer
o Nitrosoureas (-mustines)
• SERMs – block estrogen binding to ER (+) cells
o Tamoxifen and raloxifene
Metaplasia of trachea in smokers
KNOW
Ciliated Columnar cells → squamous epithelium
No cilia --- no movement of mucosa --- chronic bronchitis
Barrett’s esophagus: squamous ------ columnar
Kartagener’s Syndrome
• Also know as – Primary Ciliary Dyskinesia
• Clinical presentation
o Chronic infections (Poor mucus clearance)
o Infertility
o Hearing loss

• Dynein is nonfunctional
• Associated with dextrocardia (organs on opposite side of the body
Embryonic Structures that make up the Diaphragm
KNOW***
• Septum transversum
• Pleuropertoneal membranes
• Dorsal mesentery of the esophagus
• Abdominal wall
• Memorize these
Diaphragm Innervation
• Innervated by the phrenic nerve (C3-C5)

“C3, C4, C5 – keep the diaphragm alive”
Structures that Course through the Diaphragm
• T8 – IVC
• T10 – esophagus, vagus nerve
• T12 – aorta, thoracic duct, azygos vein

“Red, White, Blue”

“I ate ten eggs at twelve”
Type I Pneumocyte (epithelial cell)—important in gas exchange
o Very important: they are UNABLE TO REPLICATE
o Very susceptible to toxic inhalants
o 97% of epithelial cells
Type II pneumocyte (epithelial cell)
o Secretes surfactant—decreases surface tension to increase compliance
o Important during lung damage because they can replicate and even differentiate into Type I pneumocytes
Lecithin-to-Sphingomyelin ratio (KNOW)
o > 2 – fetal lung maturity
o < 2 – may need to give steroids
What structures traverse the diaphragm, and at what vertebral levels do they pass through?
“I ate ten eggs at twelve”
o T8 – IVC
o T10 – esophagus, vagus nerve
o T12 – aorta, thoracic duct, azygos vein
What is the difference between a hiatal hernia and an incisional hernia after an abdominal surgery?
• Hiatal hernia
o Peritoneal contents herniated through the diaphragm into the thorax

• Incisional hernia
o Defect in the abdominal wall
o Abdominal contents to bulge outward
What histological change takes place in the trachea of a smoker?
Metaplasia (columnar --- squamous)
A patient in the ER is having anaphylaxis. You make an incision beneath thyroid cartilage to establish airway. What structure was cut?
• Cricothyroid membrane
What cell type proliferates during lung damage?
• Type II pneumocytes
What amniotic fluid measurement is indicative of fetal lung maturity?
• Lecithin-to-Sphingomyelin Ratio > 2.0
A young woman has infertility, recurrent URIs, and dextrocardia. Which of her proteins is defective?
• Kartagener syndrome: Dynein arm defect
Chronic sinusitis, infertility and situs inversus
Kartagener syndrome
Lecture 96: Pulmonary 2
Lung Volumes and Pulmonary Circulation
Which cytokines are produced by Th1 cells? Which cytokines are produced by Th2 cells?
•Th1
o IL-2
o IFN-y
o Remember : these lead to activation CD8 cells and macrophages

• Th2
o IL-4
o IL-5
o IL-10
o Remember: activates B cells and leads to protective via antibodies
At what age can children stop using a booster seat?
Height is a better judge: 4’9”
Which protozoal organism matches each of the following statements?
• Diarrhea in campers and hikers
o Giardia
• Itchy vaginitis
o Trichomonas
• Sandfly is the vector
o Leishmania
• Ixodes tick is the vector
o Babesia
o Borrelia sp
• Anopheles mosquito is the vector
o Plasmodium
• Sodium stibogluconate is the treatment
o Leishmania
• Suramin or melarsoprol is the treatment
o Trypanosome
• Maltese cross seen in RBCs
o Babesia
• Treat with metronidazole
o Giardia
o Entamoeba
o Trichomonas
• Severe diarrhea in AIDS patients
o Cryptosporidium
• Surfactant
o Decreases alveolar surface tension
o Produced by type II pneumocytes
• ACE
o Converts Angiotension I --- Angiotensin II
o Inactivates bradykinin
o With ACE inhibitors in addition to preventing formation of ANG II will allow Bradykinin to stick around longer
• Kallikrein
o Cleaves plasminogen--- produces plasmin
o Cleave HMWK--- produces bradykinin
• Histamine
o Causes bronchoconstriction
• Prostaglandins
o Causes bronchodilation
Inspiratory reserve volume (IRV)
*HY*
o The extra amount of air that you bring into the lungs with a large inhalation
o Reserve lung volume you have
Tidal volume (TV)
*HY*
o Normal amount of air you move in and out of the lungs with each breath
Expiratory reserve volume (ERV)
*HY*
o Volume of air you can force out of your lungs with beyond what you do normally
Residual volume (RV)
*HY*
o Amount of air that is left your lungs after you have inhaled as much as possible
Inspiratory capacity (IC)
*HY*
o IRV + TV= IC
Vital capacity (VC)
*HY*
o VC= ERV + IC
o You breathe in as deeply as you can and you exhale as deeply as you can
Functional residual capacity (FRC)
*HY*
o Amount of air left in the lungs after normal relaxed expiration
o FRC= ERV + RV
Determination of Physiologic Dead Space
(HIGH YIELD – 3 star topic ***
• Physiologic dead space= area in the lungs that is not participating in gas exchange

• Anatomical dead space= Air in the airway ie. air in bronchi & bronchioles

•Functional dead space
o Apices—capable of gas exchange but no gas exchange is actually happening because there is less blood flow there

•VD = VT x (PaCO2 – PECO2) / PaCO2
• COPD
o Low alveolar oxygen
o Chronic vasoconstriction
o Pulmonary hypertension
o Cor pulmonale
Cor pulmonale
Lung disease that causes heart disease because there will be vasoconstriction wherever there is poor oxygenation
Primary pulmonary HTN
aka Idiopathic Pulmonary Arterial Hypertension

KNOW cause!
Associated with abnormalities in BMPR2: Bone Morphogenetic Protein Receptor type II

Associated with HIV and Kaposi sarcoma (HHV-8)

More common in women, average age is 36
Secondary pulmonary HTN

KNOW causes!
o Chronic lung disease
o Mitral stenosis
o Recurrent thromboemboli
o Autoimmune disease
o Left to right shunts (VSD)
oSleep apnea or living at high altitudes which causes chronic pulmonary vasoconstriction
The following lung volumes are obtained from an elderly smoker: FRC 5.0L, IRV 1.5L, IC 2.0L, VC 3.5L. What is the total lung capacity?
(VERRRY HIGH YIELD)
• TLC= IC (2.0 L) + FRC (5.0L)
• 7.0 L
If a lung collapses, what happens to the intrathoracic volume?
• Intrathoracic volume increases due to chest wall expansion
What gene mutation can cause primary pulmonary hypertension?
BMPR2 mutation
What are some of the secondary causes of pulmonary hypertension?
o COPD
o Sleep apnea
o Frequent thromboembolism
o Mitral stenosis
o Left-to-right shunt
What are some of the treatment options available for pulmonary hypertension?
• Bosentan or ambrisentan
• Prostaglandin analog
• Sildenafil
• Nifedipine
What is the mechanism of action of bosentan?
• Antagonist at the endothelin-1 receptor: Decrease pulmonary vascular resistance
Lecture 97: Pulmonary 3
Oxygen & hemoglobin
What are the Kubler-Ross grief stages?
“Death Always Brings Great Acceptance”
o Denial
o Anger
o Bargaining
o Grief
o Acceptance
What is the life-span of an RBC (which is the maximum time to expect foreign RBCs to be in a patient after a blood transfusion)?
• 120 days
What drugs and endogenous hormones regulate the secretion of gastric acid?
• Hormones:
o Promote gastric acid secretion: Histamine, Acetylcholine, Gastrin
o Inhibit gastric acid secretion: Prostaglandins, Somatostatin, Secretin, GIP

•Drugs that regulate secretion
o PPIs
o H2 blockers
o Antimuscarinic drugs
Hemoglobin (HbA)
o 2 alpha globins
o 2 beta globins
Hemoglobin (HbF)
o 2 alpha globins
o 2 gamma globins
Taut form of Hemoglobin
o T form (taut)
-Low affinity for oxygen
-Favors tissues
Relaxed form of hemoglobin
o R form (relaxed): High affinity for oxygen
Substances that favor the taut form of hemoglobin (shifts curve to the RIGHT)
* HIGH YIELD*
oCO2
o Hydrogen ions (H+)
-As muscles are being used they produce lactic acid--- this increases H+
o Increased temperature
- Muscles also increase temperature when they are being used
o Increased 2,3-DPG (2,3-BPG)
- Diphosphoglycerate or Bisphophoglycerate
o Favors O2 will be unloaded at the tissues
o Shift in the curve to the right= less oxygen saturation at a given PO2 than normal
Substances that favor the R form of hemoglobin (shifts curve to the LEFT)
*HIGH YIELD*
o Decreased CO2
o Decreased 2,3-DPG
o Decreased Hydrogen ions (H+)
o Decreased temperature
o Shift to left= more oxygen saturation at a given PO2 than normal
o Fetal hemoglobin has a higher affinity for O2 so their curve is always shifted to the left
-Higher affinity for O2 is due to decreased affinity for 2,3-DPG
What substances are known for causing methemoglobinmia?
o Nitrates and nitrites: Most common cause because they are used most frequently
o Anti-malarial drugs: Chloroquine, Primaquine
o Dapsone
o Sulfonamides
o Local anesthetics: Lidocaine
o Metoclopramide
Which form of hemoglobin A has a high affinity for oxygen? Which has a low affinity for oxygen?
o T form (taut): Low affinity for oxygen

o R form (relaxed): High affinity for oxygen
What substances tend to shift the oxygen-hemoglobin dissociation curve to the right? Does this favor oxygen loading or unloading?
• CO2
• Elevated 2,3-DPG (2,3-BPG)
• Exercise and activity
• Acidosis
• Increased temperature
• Favor unloading to the tissues
What is the treatment for methemoglobinemia?
o Methylene blue
o Vitamin C
Lecture 98: Pulmonary 4
Oxygenation & Ventilation
What is the characteristic sequence of the promoter region? What does a mutation in the sequence cause?
• -25 TATA box (Hogness box)
• -75 CAAT box
• Mutation – less transcription of genes
What are the pathological characteristics of the arteries in pulmonary hypertension?
• Medial hypertrophy
• Fibrosis of the intima
• Atherosclerosis
RLE: Urea cycle
o Carbamoyl phosphate synthase-I
RLE: Hexose monophosphate pathway
o Glucose-6 phosphate dehydrogenase
RLE: Fatty acid synthesis
o Acetyl CoA carboxylase
RLE: B- oxidation of fatty acids
o Carnitine acyltransferase
RLE: Ketone body synthesis
o HMG-CoA synthase
RLE: Cholesterol synthesis
o HMG-CoA reductase
RLE: Bile acid synthesis
o 7-a hydroxylase
RLE: Heme synthesis
Aminolevulinate synthase
Alveolar Gas Equation
*KNOW*
PAO2= 150 x PaCO2/ (0.8)
A-a gradient
o PAO2 – PaO2
o Difference between oxygen content in alveolars & arteries
o There should not be a large difference
Things that increase the A-a gradient (increased A-a gradient)
o Shunting or V/Q mismatch
o Pulmonary fibrosis
o Increased FIO2
o Age
(PaO2)/ (FiO2 )
o 300-500 mmHg is normal
o < 300 gas exchange deficit
o < 200 severe hypoxia
• Oxygen deprivation
o 1. Decrease PaO2
o 2. Decrease O2 delivery to tissues
o 3. Loss of blood flow
• Decreased PaO2 (hypoxia)
o High altitude
o Hypoventilation
o Pulmonary fibrosis
o Right-to-left shunt
o V/Q mismatch
• Decreased O2 delivery to tissues
o Hypoxemia
o Anemia
o CO poisoning
o Heart failure
• Loss of blood flow
o Impeded arterial flow (MI, stroke)
o Reduced venous drainage
V/Q Mismatch
HIGH YIELD – 3 star/ 4 star topic****
• Perfusion is great at the base of the lung

• Ventilation is greater at the apex of the lung

• V/Q approaches zero (shunting)
o Low ventilation
o High perfusion
o Caused by airway obstruction

•V/Q approaches infinity
o High ventilation
o Low perfusion
o Caused by obstruction or physiologic dead space
What is the normal value for the A-a gradient? What might an elevated A-a gradient indicate?
• 10-15 mmHg
• Elevated A-a Gradient
o High FiO2 (from supplemental oxygen)
o Shunting of blood
o Pulmonary fibrosis (impaired gas diffusion)
o V/Q mismatch
o Advanced age
A 42-year-old woman with fibroids is chronically tired. What is the most likely diagnosis, and what changes have occurred in the oxygen content and saturation?
• First part of question
o She is most likely anemic
o Reduced amount of hemoglobin to be saturated

• Second part of question
o No change in oxygen saturation
o Total oxygen content in the blood is low
A patient is shown to have hypoxia, and CXR reveals an enlarged heart. What is the most likely cause of hypoxia?
• Heart failure
What is the V/Q at the apex of the lung? At the base of the lung? During airway obstruction? During blood flow obstruction?
• V/Q Values
o Apex of the lung – greater than 1
o Base of the lung – less than 1
o During airway obstruction – Towards 0 (shunting)
o During blood flow obstruction – Towards infinity (dead space)
How is CO2 transported from the tissues to the lungs?
1. Transported as bicarbonate (most important way)
2. Transported bound to hemoglobin at N terminus
3. Dissolved in blood
How do CO2 levels in circulation change during exercise?
• No change in arterial CO2 levels
• Increased in venous CO2 levels
Lecture 99: Pulmonary 5
Extreme environments
In what disorder is there an abnormal breakdown of elastin?
a1-antitrypsin deficiency
What is the name of the genetic syndrome that fits each of the following descriptions?

• Alcoholics with B1 deficiency and neurologic defects
o Pyruvate dehydrogenase deficiency
• Abnormal type I collagen synthesis
o Osteogenesis imperfecta
• Heinz bodies
o G6PD deficiency
• Musty/mousy odor, albinism, MR, eczema
o PKU
• Hyperextensible skin, loose joints, bleeding tendency
o Ehlers-Danlos
• Hypoglycemia, jaundice, cirrhosis
o Fructose intolerance
• Bloating, cramps, osmotic diarrhea
o Lactose intolerance
Dark brown urine, organs, and connective tissue; benign disease
o Alkaptonuria
• Multiple fractures and blue sclera
o Osteogenesis imperfecta
What questions are asked during the 4 clinical phases of drug development?
• Phase I – Is it safe?
• Phase II – Does it work?
• Phase III – Does it work better?
• Phase IV – Post-market surveillance
****THESE ARE HIGH YIELD TOPICS****
soooo listen up
High Altitude
• Increased ventilation
• Increased erythropoietin (more RBCs)
• Increased 2,3-DPG
• Increased mitochondrial tissue
• Increased renal excretion of bicarb: Respiratory alkalosis with metabolic compensation
What are the clinical derangements that come about in a patient with acute mountain sickness?
• Due to hypoxia induced vasodilation
o Headache
o Fatigue
o Acute pulmonary edema
o Acute cerebral edema
What physiological changes occur during chronic mountain sickness?
• Increased RBC mass and hematocrit
• Increased blood viscosity
• Decreased tissue blood flow
• Elevated pulmonary artery pressure
• Right-sided heart enlargement
• Peripheral artery pressure falls
• CHF
At what positive G-force does a visual “black-out” occur?
• 4-6 Gs
What G-force is achieved during a spacecraft liftoff?
8-9 Gs
How is the body affected at zero gravity?
• Decreased blood volume
• Decreased RBC mass
• Decreased muscle strength/work capacity
• Decreased maximum cardiac output
• Loss of calcium and phosphate, resulting in loss of bone mass
What is nitrogen narcosis?
• Nitrogen, dissolves into the neural membranes which causes reduced neuronal excitability
• Diver becomes jovial/careless
• Loss of strength and coordination
• Loss of calcium and phosphate
• Look similar to alcohol intoxication
What are the symptoms of decompression sickness?
• Pain in the joints and muscles of arms and legs

• Neurologic problems
o Dizziness
o Paralysis
o Syncope

• Chokes
o Shortness of breath
o Pulmonary edema
How does the body compensate for hypoxia at high altitude?
• Increased ventilation
• Increased renal excretion of bicarb
• Increased mitochondrial tissue
• Increased erythropoietin (more RBCs)
• Increased 2,3-DPG
How much does the H&H change in a person that has acclimatized to a hypoxic environment for weeks?
Hematocrit: 40-45 increased to 60
Hemoglobin: 15g/dL increased to 20g/dL
At what positive G force does visual “black-out” occur? Why does this occur?
• 4-6 Gs
• Centrifugal force pooling blood in the abdomen and legs
• Insufficient blood to heart and brain
What physiologically is taking place in decompression sickness?
o Ascend from a dive, high to low pressures
oGases (nitrogen) dissolved in blood being to escape dissolved state forming bubbles
oBubbles can occlude blood vessels
For what conditions is hyperbaric oxygen therapy particularly helpful?
o Decompression sickness
o Arterial gas embolism
o Carbon monoxide poisoning
o Gas gangrene
o Osteomyelitis
By what physiological mechanism does acute mountain sickness cause acute cerebral edema and acute pulmonary edema?
• Hypoxia-induced vasodilation
Lecture 100: Pulmonary 6
PE and DVT
Which immunosuppressant matches each of the following statements?
• Precursor of 6-mercaptopurine
o Azathioprine
• May prevent nephrotoxicity and mannitol dieresis
o Cyclosporine
• Antibody that binds to CD3 on T cells
o Muromonab
• Antibody that binds IL-2 receptor on activated T cells
o Daclizumab
• Inhibits inosine monophosphate dehydrogenase
o Mycophenolate mofetil
• Inhibits calcineurin leads toa loss of IL-2 production which causes blockage of T cell differentiation and activation
o Cyclosporine
• Metabolized by xanthine oxidase, therefore allopurinol increases its toxicity
o Azathioprine
What is the treatment for homocystinuria?
• Decrease methionine
• Increase cystine
• Increase B6
• Increase B12
• Add folate
What are the treatments of choice for each of the following protozoa?
• Trichomonas vaginalis
o Metronidazole
• Trypanosome cruzi
o Nifurtimox
• Plasmodium vivax
o Chloroquine + primaquine
• Leishmania donovani
o Sodium stibogluconate (cutaneous)
o Amphotericin B (visceral)
• Entamoeba histolytica
o Metronidazole
• Toxoplasma gondii
o Sulfadiazine + pyrimethamine
Caisson disease
“The bends”
Decompression illness
Scuba diving at great depths and come up too quickly
Air embolus
A patient suffers a stroke after incurring multiple long bone fractures in a skiing accident. What caused the infarct?
• Fat embolus
• Patient would have to have a Patent foramen ovale
-Allows the embolus to go from the venous side to the arterial side
A patient with a recent tibia fracture and no history of COPD or asthma is shown to have hypoxia. CXR is normal. What is the cause of the hypoxia, and what disease process does it mimic?
Pulmonary Embolus (possibly mimicking an MI)
Elevated D-dimers
Pulmonary embolism
DVT
Hypercoagulability, endothelial damage, stasis of blood
Virchow’s triad
What diagnosis is associated with these classic EKG findings. A wide S wave in lead I, a large Q in lead III, and an inverted T wave in lead III?
• Pulmonary embolism
Lecture 101: Pulmonary 7
COPD and Asthma
What can be seen in erythrocytes in patients that do not have a functional spleen?
• Howell-Jolly bodies
A HIV (+) patient with a CD4 count of 75 presents with signs of meningitis. Examination of the CSF reveals a heavily encapsulated organism. What organism is responsible for the meningitis?
• Cryptococcus neoformans
What is the difference between direct bilirubin and indirect bilirubin?
• Direct bilirubin is conjugated (with glucuronic acid)
• Indirect bilirubin is unconjugated: INdirect is UNconjugated
Obstructive vs. Restrictive Lung volume & FEV1/ FVC ratio
*KNOW*
Obstructive: Increased lung volume & Decreased FEV1/ FVC

Restrictive: Decreased lung volume & Normal FEV1/ FVC
Normal FEV1/ FVC
80%
What is the differential diagnosis for eosinophilia?
Drugs
Neoplasms
Atopic diseases (allergy, asthma, Churg-Strauss)
Addison disease
Acute interstitial nephritis
Collagen vascular disease
Parasites (Loffler eosinophilic pneumonitis)
a1-Antitrypsin deficiency
Young age of onset (20-30 yrs)
Non-smokers
Early-onset cirrhosis
Overactive elastase leads to destruction of elastic lung tissue
A patient present with asthma attack. What immunological reaction is taking place that is responsible for anaphylaxis in this patient?
• Antigen crosslinking IgE on pre-sensitized mast cells
What asthma medication fits each of the following statements?
• Inhaled treatment of choice for chronic asthma
o Inhaled steroid
• Inhaled treatment of choice for acute exacerbations
o Albuterol or Levalbuterol
• Narrow therapeutic index, drug of last resort
o Theophylline or aminophylline
o Antidote of theophylline is B blockers
• Blocks conversion of arachidonic acid to leukotrienes
o Zileuton
• Inhibits mast cell release of mediators, used for prophylaxis only
o Cromolyn
• Inhaled treatment that blocks Muscarinic receptors
o Ipratropium
o Tiotropium
• Inhaled long-acting B2 agonist
o Salmeterol
• Blocks leukotrienes receptors
o Zafirlukast
o Montelukast
o Also treats allergic rhinitis
A patient has an extended expiratory phase. What is the disease process?
• Obstructive lung disease
What is the hallmark sign of COPD? What is the hallmark sign of a restrictive lung disease?
• COPD
o Decreased FEV1/FVC ratio

• Restrictive lung disease
o Decreased total lung capacity
o Normal FEV1/FVC ratio
How does the emphysema caused by smoking differ from the emphysema caused by alpha-1-antitrypsin deficiency?
o Smoking: Centriacinar
o a1-Antitrypsin deficiency: Panacinar
Blue bloater
Chronic bronchitis
Pink puffer
Emphysema
Curschmann’s spirals
Asthma
Most common cause of pulmonary hypertension
COPD
Lecture 102: Pulmonary 8
Restrictive Lung Disease
What are the two HIV envelope proteins and the drugs that interfere with them?
• Gp120 – Maraviroc
• Gp41 – Enfuvirtide
A patient has a genetic disease in which the treatment includes protein restriction to prevent mental retardation, ketoacidosis, and death. What is the diagnosis?
• Maple Syrup Urine Disease
What pathology fits each of the following high-yield statements?
• Opacities seen on x-ray on both sides of the carina
o Sarcoidosis
• Dermatitis, diarrhea, dementia, possibly death
o Niacin deficiency (pellagra)
• Greenish rings around the periphery of the iris
o Wilson disease
• Elastic skin, joint hypermobility
o Ehlers-Danlos syndrome
• Enlarged, hard, left supraclavicular lymph node
o Virchow’s node
Lewis Notes (HIGH YIELD)
• Langerhans cells
o Eosinophilic granuloma (histoplasmosis)
• Anti-basement membrane Ab
o Goodpasture
• Increased ACE levels
o Sarcoidosis
• Organic Dusts (farmers)
o Hypersenstivitiy pneumonitis
• Black deposits, asymptomatic
o Anthracosis
• Carbon dust, no cancer risk
o Coal worker’s
• Ferruginous bodies
o Asbestosis
• Sand blasting
o Silicosis
• Beryllium exposure
o Berylliosis
A preterm infant has difficulty breathing. An x-ray reveals diffuse air space and interstitial opacities, with air bronchograms. What is the diagnosis, and what could have prevented this condition?
• Neonatal Respiratory Distress syndrome
o Prevented with maternial steroids 24-48 hours prior to delivery
What are common causes of ARDS?
•Shock
•Infection
•Toxic gas inhalation
•Acute pancreatitis
•Aspiration
•Heroin overdose
•High concentrations of O2 for extended periods of time
H&E of lung biopsy from a plumber shows elongated structures with clubbed ends in tissue. What is the diagnosis, and what is he at increased risk for?
DX: Asbestosis
Increased risk for: Mesothelioma, Bronchogenic carcinoma
What are the manifestations of sarcoidosis?
• Granulomas
• RA
• Uveitis
• Erythema nodosum
• Lymphadenopathy (bilateral hilar)
• Idiopathic
• Not TB
• Gammaglobulinemia
• Increased ACE
• Increased Vitamin D
• Increased Ca+2
What do patients with silicosis need to be worried about?
• Increased susceptibility to TB
Bilateral hilar adenopathy, uveitis
Sarcoidosis
Vasculitis and glomerulonephritis
Wegener’s granulomatosis
Goodpasture syndrome
Anti-glomerular basement membrane antibodies
Goodpasture syndrome
Honeycomb lung on x-ray
Interstitial fibrosis
“Tennis-racket” shaped cytoplasmic organelles
Birbeck granules (eosinophilic granuloma)
Lecture 103: Pulmonary 9
Lung cancer and infections
What substance is important for relaxing the lower esophageal sphincter?
• Nitric Oxide
What is the triad of Kartagener syndrome? What is the underlying defect?
o Triad
-Sterility
- Bronchiectasis
- Recurrent sinusitis

o Infertility

o Dynein arm defect
What pathology fits each of the following high-yield phrases?
• Gout + mental retardation + lip-biting
o Lesch-Nyhan syndrome
•Lack of Gp IIb/IIIa causesdefect in platelets and prolonged bleeding
o Glanzmann thrombasthenia
• Anti-histone antibodies
o Drug-induced lupus
• Psammoma bodies
o Papillary adenocarcinoma of the thyroid
o Serous cystadenocarcinoma of ovary
o Meningioma
o Mesothelioma
• Lytic bone lesions on x-ray
o Multiple myeloma
****HIGEST YIELD – identifying the different types of lung cancers – 4 star/5 star topic ****

• Most common lung cancer is non-smokers
Adenocarcinoma
• Small cell
o Lambert- Eaton Syndrome
o Myc oncogene
o S mnemonic
-Small cell
-Smoking
-Central
-Secreting
• Carcinoid
o Bronchospasm
o Flushing
o Diarrhea
o Right-sided valvular lesions
• Lung cancer tends to metastasize to
o Brain
o Bone
o Liver
Lewis Notes *High Yield*
-Location, Smoking, Characteristics
Adenocarcinoma
Peripheral

+/-

Most common
K-RAS oncogen
CEA
Bronchioalveolar
Peripheral

Smoking: -

Looks pneumonia
Large cell
Peripheral

Smoking: +

Anaplastic
Poor prognosis
Chemo doesn’t work
Squamous cell
Central

Smoking: ++

Keratin pearls
Cavitativion
PTHr-P causes increased Ca
Small cell
Central

Smoking:++

Undifferentiated
Secretes – ACTH, ADH
Lambert- Eaton
Carcinoid
Lung/GI

Smoking: neg

Serotonin – flushing, diarrhea
Pancoast
Pleura

Smoking: neg

Asbestosis
Poor prognosis
Ship builders, plumbers
Which infectious agent fits each of the following descriptions? (HIGHESSSST YIELD Pneumonia info)

• Common cause of pneumonia in immunocompromised patients
o Pneumocystis jirovecii
• Most common cause of atypical/ walking pneumonia
o Mycoplasma pneumoniae
• Common causative agent for pneumonia in alcoholics
o Klebsiella pneumoniae
• Can cause interstitial pneumonia in bird handlers
o Chlamydia psittaci
• Often the cause of pneumonia in a patient with a history of exposure to bats and bat droppings
o Histoplasma capsulatum
• Often the cause of pneumonia in a patient who has recently visited South California, New Mexico, or West Texas
o Coccidioides immitis
• Pneumonia associated with “currant jelly” sputum
o Klebsiella pneumoniae
• Q fever
o Coxiella burnetii
• Associated with pneumonia acquired from air conditioners
o Legionella pneumophila
• Most common cause of pneumonia in children 1-year-old or younger
o Respiratory syncytial virus (RSV)
• Most common cause of pneumonia in the neonate
o Group B Strep
o E. coli
• Most common casue of pneuomonia in children and young adults (including college students, military recruits, and prison inmates)
o Mycoplasma pneumoniae
• Common cause of pneumonia in patients with other health problems
o klebsiella pneumoniae
• Most common cause of viral pneumonia
o Respiratory syncytial virus (RSV)
• Causes wool-sorter’s disease (a life-threatening pneumonia)
o Bacillus anthracis
• Endogenous flora in 20% of adults
o Streptococcus pneumoniae
• Common bacterial cause of COPD exacerbation
o Haemophilus influenzae
• Common pneumonia in ventilator patients and those with cystic fibrosis
o Pseudomonas aeruginosa
• Pontiac fever
o Legionella pneumonphila
A patient develops bronchogenic lung cancer but has never smoked. He is a coal miner. Exposure ot what substance has put him at risk for developing lung cancer?
• Radon gas
What complications can arise from lung cancer?
• Superior vena cava syndrome
• Horner syndrome
• PTH related peptide causes hypercalcemia
• ACTH causes Cushing syndrome
• SIADH causes hyponatremia
• Labert-Eaton syndrome
• Hoarseness
• Pleural effusions
• Dysphagia
• Laryngeal invasion
What are the 3 most common locations of lung cancer mets?
• Brain
• Bone
• Liver
Examination of a lung at autopsy reveals a peripheral lesion with caseous necrosis. What is the diagnosis?
• Tuberculosis
A 30-year-old comatose man on ventilator support in the ICU develops an infection and dies. Autopsy reveals a pus-filled cavity in his right lung. What is the likely etiology?
• Aspiration causes Lung Abscess
What infectious agent is the cause of pneumonia, based on each of the following lab tests?
• Gram (+) cocci in clusters
o Staphylococcus aureus
• Gram (+) cocci in pairs
o Streptococcus pneumoniae
• Gram (-) rods in 80-year-old
o E. coli
• Gram (+) cocci in neonate
o Group B strep
• Gram (-) rods in neonate
o E. coli
Most common causes of nosocomial pneumonia
Klebsiella
E. coli
Pseudomonas
Lung cancer associated with SIADH
Small cell lung cancer
Iron-containing nodules in the alveolar septum
Ferruginous bodies causes asbestosis
Lecture 104: Micro 6
Bacterial Basics
A 50-year-old obese man with hypertension comes to your clinic to receive care for his chronic fatigue. A CBC is preformed and an elevated H&H is discovered. What is the most likely cause of elevated hemoglobin level?
• Sleep apnea-induced erythrocytosis
o Hypoxia over night causes increased erythropoietin levels
What are the acute phase cytokines?
• IL-1
• IL-6
• TNF- a
How does the brain utilize ketone bodies?
• Ketone bodies: 2 acetyl-CoA
Quellung reaction
KNOW
o Specific anticapsule sera antibodies will cause swelling of the bacteria
o Test that determines if the organism has a capsule
Encapsulated Bacteria
“Even Some Pretty Nasty Killers Have Shiny Bodies”
E. coli (some strains)
Strep pneumoniae
Pseudomonas aeruginosa
Neisseria meningitidis
Klebsiella pneumoniae
Haemophilus influenzae
Salmonella typhi
Group B strep

Capsules can serve as antigens in vaccine

Capsule is a virulence factor
Giemsa stain
*HY*
o Borrelia
o Plasmodium
o Trypanosomes
o Chlamydia
o Histoplasma
o * When in doubt guess Giemsa
Periodic acid-Schiff –
*HY*
o Glycogen
o Mucopolysaccharides
o Used to diagnose Whipple’s disease: Tropheryma whippelii
Ziehl-Neelsen
*HY*
o Acid fast organisms
o Mycobacteria
India ink
*HY*
o Cryptococcus neoformans
Silver stain
*HY*
o Fungi: Pneumocystis jirovecii
o Legionella: “Legioner wears a silver helmet”
Transformation (genetic transfer)
o “SHiN”
-Strep pneumo
-H influenzae type B
-Neisseria spp. (Neisseria meningitides)

o Encapsulated bacteria that cause meningitis
o How they get ABX resistance
Conjugation
o Via Sex pilus
o Do not exchange chromosomal genes, only plasmids (for the most part)
Transposition
o Jumping of genes
Transduction
o Via bacteriophage
What bacterial structures have the following functions?

• Mediates adherence of bacteria to the surface of cell
o Fimbria or pili
• Protects against phagocytosis
o Capsule
• Provides rigid support to bacterial cell and protects against osmotic pressure differences
o Peptidoglycan layer
• Space between the inner and outer cellular membranes in Gram (-) bacteria
o Periplasm
• Motility
o Flagella
• Bacterial form which provides resistance to dehydration, heat, and chemicals
o Spore
• Forms attachement between two bacteria during transfer of DNA material (aka conjugation)
o Sex pilus (F pilus)
• Genetic material within bacteria that contains genes for antibiotic resistance
o Plasmid
What stain is required to see the following organism (or substance)?
• Cryptococcus neoformans
o India ink
• Pneumocystis jirovecii (PCP)
o Silver stain
• Chlamydia
o Giemsa stain
Which organisms do not take Gram stain?
• Treponema
o Cell wall is too thin
• Rickettsia
o Intracellular
• Chlamydia
o Intracellular
• Legionella
o Intracellular
• Mycoplasma pneumonia
o Have no cell wall
• Mycobacteria
o High lipid content
By what method are plasmids exchanged between bacteria?
• Conjugation